Consensus document on palliative care in cardiorenal patients

There is an unmet need to create consensus documents on the management of cardiorenal patients since, due to the aging of the population and the rise of both pathologies, these patients are becoming more prevalent in daily clinical practice. Chronic kidney disease coexists in up to 40%–50% of patients with chronic heart failure cases. There have yet to be consensus documents on how to approach palliative care in cardiorenal patients. There are guidelines for patients with heart failure and chronic kidney disease separately, but they do not specifically address patients with concomitant heart failure and kidney disease. For this reason, our document includes experts from different specialties, who will not only address the justification of palliative care in cardiorenal patients but also how to identify this patient profile, the shared planning of their care, as well as knowledge of their trajectory and the palliative patient management both in the drugs that will help us control symptoms and in advanced measures. Dialysis and its different types will also be addressed, as palliative measures and when the decision to continue or not perform them could be considered. Finally, the psychosocial approach and adapted pharmacotherapy will be discussed.


INTRODUCTION AND BACKGROUND: THE NECPAL PROGRAM
The NECPAL Program was built to respond the challenge of timely, comprehensive, and integrated palliative approach and care for people with advanced chronic conditions from all causes in all settings of the health ad social systems, and has included research, education, and knowledge transfer.The tool has been translated and validated in many cultures, and used intensively in many countries.

The NECPAL utilities
The NECPAL utilities have been so far the screening of people with palliative care needs in services, which allows the determination of their prevalence, and to elaborate a basic checklist of their needs.In the evolutive updating of the tool, it has been improved, adding some criteria as the geriatric and psychosocial issues, and defining more precisely the existing parameters.

Developing the NECPAL 4.0 PROGNOSTIC
The aim of designing the NECPAL 4.0 PROGNOSTIC is to explore its prognostic utility, and has included different steps: literature review, expert's consensus, building a predictive model, and testing it's validity with a retrospective analysis of a cohort recruited previously.

HOW TO USE IT IN PRACTICE IN HEALTH AND SOCIAL SERVICES?
Steps: the first steps are similar to the previous versions: 1. Review the list of people attended by the service.
2. Elaborate a list of those persons with chronic conditions specially affected.
3. Apply the surprise question to doctors and nurses about well-known patients: "Would you be surprised inf this patient die in one year?"with clinical criteria.
4. In those patients in which the response was "I'm or we will not be surprised", explore the different NECPAL generic parameters and the specifics for conditions.
The result of this procedure will be list of patients having palliative care needs and a limited life prognosis (Figure 1: NO, I would not be surprised YES, I would be surprised NOT NECPAL

Would you be surprised if this patient dies within the next year?
"Demand" or "Need" -Demand: Have the patient, the family or the team requested in implicit or explicit manner, palliative care or limitation of therapeutic effort?

Persistent symptoms
Pain, weakness, anorexia, digestive...  3. Elaborate aims and actions to respond to the identified needs.

Psychosocial aspects
4. Elaborate a comprehensive therapeutic plan.The result of this procedure permits to identify palliative care needs and elaborate a comprehensive therapeutic plan:

Multidimensional assessment
Actions for the comprehensive care of people identified > "Situational" Checklist: identification of the prognostic risk to elaborate the prognostic approach: • Situational prognostic checklist • Risk estimation • Criteria for prognostic approach Listing the parameters with prognostic utility (palliative needs identified by professionals, functional decline, nutritional decline, multimorbidity, increased use of resources, and parameters of the specific disease.
The result of this procedure includes the patient MACA in one of these three prognostic stages:

ASPECTS TO CONSIDER
How to manage the prognostic assessment in clinical practice 1.The prognosis is one of the elements to consider, added to the needs and demands .

2.
The prognostic risk is applied to populations that accomplish criteria, but must be applied with caution to individual patients.

3.
Once established, we will have a prognostic situational perspective, which can be valuable for a therapeutic approach.

4.
It is recommended to update it regularly.
Risks and benefits of the prognostic approach 1.The most relevant benefit of the prognostic assessment is to contribute to the situational assessment and permits redefinition of the therapeutic aims, introducing gradually a palliative approach.
2. This assessment must be shared with patients, relatives and team, with the rithm, intensity, and concretion adapted individually to the adjustment and preferences of patients.

3.
The most relevant risk consists in the automatic individual application of a population-based risk.

P
Pr ro of fe es ss si io on na al ls s t th hi in nk k t th ha at t h he e/ /s sh he e h ha as s p pa al ll li ia at ti iv ve e c ca ar re e n ne ee ed ds s FUNCTIONAL DECLIVE C Cl li in ni ic ca al l a as ss se es ss sm me en nt t o of f f fu un nc ct ti io on na al l d de ec cl li in ne e s su us st ta ai in ne ed d, , s se ev ve er re e a an nd d i ir rr re ev ve er rs si ib bl le e NUTRITIONAL DECLINE C Cl li in ni ic ca al l a as ss se es ss sm me en nt t o of f n nu ut tr ri it ti io on na al l d de ec cl li in ne e s su us st ta ai in ne ed d, , s se ev ve er re e, , a an nd d i ir rr re ev ve er rs si ib bl le e MULTI-MORBIDITY M Mo or re e t ta an n 2 2 c ch hr ro on ni ic c d di is se ea as se es s a ad dd de ed d t to o t th he e p pr ri in nc ci ip pa al l c co on nd di it ti io on n ev ve er ri it ty y o r p pr ro og gr re es ss si io on n o of f c ch hr ro on ni ic c c co on nd di it ti io on ns s a as s H He ea ar rt t, , R Re en na al l, , L Lu un ng g, , N Ne eu ur ro ol lo og gi ic c, , o or r H He ep pa at ti ic c ≥ ≥2 2 e em me er rg ge en nc cy y a ad dm mi is ss si io on n o or r i in nc cr re ea as se e o of f d de em ma an nd d o of f i in nt te er rv ve en nt ti io on ns s a an nd d 6 6 m mo on nt th hs s > Need's Checklist: Identification of palliative care needs to insert a palliative approach 1. Realize a rapid checklist of the need's dimensions.2. Complement with additional indicators and parameters if needed.

2.
Assessment of the stage of diseases and conditions and possible evolution 3. Identify values, preferences, and start advance care planning 4. Identify and care principal career 5. Identify and actívate referent profesional 6. Multidimensional Therapeutic Plan 7. Case management and integrated care with other services